BACKGROUND AND OBJECTIVES:The aim of this study was to quantify the relative percentage of patients with neurosarcoidosis who demonstrate persistent gadolinium enhancement on MRI, despite apparent clinical remission. METHODS:Data from 39 patients with neurosarcoidosis were collected retrospectively for use in electronic chart analysis. Data were anonymized, and patient data (demographics, clinical presentation, radiographic characteristics, and treatment profile) were collected. Standard descriptive statistics were performed, comparing populations with and without persistent gadolinium enhancement. RESULTS:There was no significant difference in disease and treatment data between patient groups with and without persistent gadolinium enhancement. Persistent gadolinium enhancement was common and not associated with clinical disease activity in patients with neurosarcoidosis. There was no correlation between radiographic and clinical improvements. DISCUSSION:Our study demonstrates that persistent gadolinium enhancement is common and does not necessarily correspond to active disease. Given that neurosarcoidosis is commonly monitored with serial MR imaging, these data suggest that persistent enhancement alone should not be used to guide treatment and needs to be taken in the context of the patients' clinical status, previous imaging findings, and examination.
BACKGROUND:Neurologic disorders are a leading cause of disability worldwide, yet US specialty care remains fragmented and reactive. Integrated population-health models that embed neurology within coordinated systems can improve access, efficiency, and outcomes. RECENT FINDINGS:We reviewed case studies from 5 diverse academic health systems-Cleveland Clinic, Mayo Clinic, Mass General Brigham, Kaiser Permanente, and Vanderbilt University Medical Center. Strategies included embedding neurologists in primary care, deploying low-cost telehealth networks, and aligning incentives for value-based care. These programs demonstrated improved timeliness, patient satisfaction, and resource utilization, while highlighting persistent challenges such as reimbursement uncertainty, workforce burnout, and digital inequities. IMPLICATIONS FOR PRACTICE:Key elements-team-based care, telehealth, and shared governance-are adaptable beyond large academic centers. Transparent cost analyses, alternative payment models, and policies addressing licensure and equity will be essential to scale integrated neurology and sustain innovation across community and rural settings.
BACKGROUND:Public awareness of concussion has grown significantly over the past 2 decades, driven largely by media coverage of sports-related injuries. This has paralleled a rise in traumatic brain injury (TBI)-related emergency department visits, underscoring the need for specialized concussion care centers. Despite this, most existing programs focus on sports or pediatric populations, leaving critical care gaps. RECENT FINDINGS:The NYU Langone Concussion Center was established in 2013 to address these gaps by providing interdisciplinary care for both sports-related and non-sports-related concussions. Approximately 60% of cases seen at the center are not sports related. This article outlines the center's inception, operational model, patient demographics, and evolution over the past decade. IMPLICATIONS FOR PRACTICE:Lessons learned from the NYU Langone model offer valuable guidance for developing comprehensive concussion programs that can serve diverse urban populations. Key strategies include cross-specialty collaboration, flexible infrastructure, and systems-level integration to address heterogeneous mechanisms of injury and outcomes.
PURPOSE OF REVIEW:Dopaminergic molecular imaging has evolved from an esoteric research tool to an indispensable adjunct in the diagnosis, management, and teaching of movement and neuropsychiatric disorders. Despite its clinical relevance, many neurology trainees encounter dopamine transporter (DAT) SPECT, [18F]FDOPA PET, and emerging vesicular monoamine transporter-2 (VMAT2) tracers only sporadically and often without a cohesive interpretive framework. This narrative review aims to provide a visually driven, clinically grounded roadmap that links dopaminergic neurochemistry and pathway anatomy to in vivo molecular imaging, with a specific focus on education and bedside application. RECENT FINDINGS:Advances in dopaminergic imaging now allow in vivo interrogation of dopamine synthesis, vesicular storage, synaptic reuptake, postsynaptic receptor signaling, and metabolism using complementary SPECT and PET radiotracers. Presynaptic techniques (FDOPA PET, VMAT2 PET, or DAT SPECT/PET) reliably detect nigrostriatal degeneration, clarify equivocal parkinsonian presentations, and highlight phenotypic variants, including genetic and drug-related mimics. Postsynaptic D2/D3 receptor imaging refines differentiation between neurodegenerative and drug-induced parkinsonism, whereas myocardial [123I]-MIBG scintigraphy adds autonomic context that strengthens separation of synucleinopathies from tauopathies. Educational strategies increasingly emphasize pathway-based interpretation, recognition of common pitfalls (such as false-negative DAT scans), and the integration of semiquantitative metrics. Emerging machine learning approaches and standardized quantification pipelines are improving reproducibility and scalability across centers. SUMMARY:By integrating dopaminergic pathway anatomy, molecular neurotransmission, and tracer-specific imaging patterns, dopaminergic scans can be transformed from isolated diagnostic tests into powerful clinical and educational tools. A visually anchored, circuit-based teaching approach-supported by schematic figures, comparative tables, and case-based discussion-enhances trainee understanding and clinical confidence. This guide aims to equip neurologists and trainees with a coherent framework for deploying dopaminergic imaging effectively at the bedside and in the classroom, while preparing the field for quantitative and theragnostic advances.
PURPOSE OF THE REVIEW:Perimenopause and menopause are reproductive stages marked by fluctuating and subsequent permanent loss of ovarian estrogen and progesterone production. There are important considerations in these life stages for people with epilepsy including the influence of hormonal changes and use of menopausal hormone therapy (HT) on seizure control and on antiseizure medication (ASM) metabolism. This narrative review summarizes the currently available information about this topic to increase provider awareness and identify gaps in knowledge for future research. RECENT FINDINGS:Menopause is associated with symptoms that can negatively affect quality of life, including vasomotor and genitourinary symptoms, mood and sleep disturbances, and cognitive changes. HT is the most effective treatment for menopause symptoms, but data on HT use in women with epilepsy are limited. HT may influence seizure control and the metabolism of some ASMs, such as lamotrigine. These observations and the limited available data may be a deterrent to the use of HT in women with epilepsy. SUMMARY:Data are largely lacking to guide the management of epilepsy during perimenopause and menopause. This review summarizes existing data and discusses HT and nonhormone therapies for management of menopause symptoms, highlighting unique considerations for those with epilepsy during the menopause transition.
BACKGROUND AND OBJECTIVES:Machine learning (ML) and natural language processing (NLP) approaches are increasingly used to support nuanced phenotyping, surveillance, and trial readiness using electronic health records (EHRs) in neurologic disease. However, inconsistent clinical documentation limits data harmonization and model performance, particularly in complex heterogeneous disorders such as neurofibromatosis type 1 (NF1). The primary research question was whether physician-authored EHR documentation of NF1-related features demonstrates systematic lexical variation that may impede computational phenotyping. The primary objective was to characterize lexical variation and documentation completeness for core NF1 features, while a secondary objective aimed to develop a standardized, data-informed clinical lexicon aligned with contemporary clinical practice and terminology standards. METHODS:We conducted a retrospective observational study of outpatient progress notes from pediatric patients with NF1 evaluated at 2 large tertiary care programs serving similar patient populations in the Midwest. A rule-based NLP algorithm was developed to identify 10 core NF1 features and extract the range of terms used to document each feature. Lexical variants and documentation frequency were quantified across institutions, providers, and time. Based on observed usage patterns, a standardized clinical lexicon was developed and mapped to existing terminology standards. RESULTS:A total of 5,393 outpatient notes representing 1,661 individual pediatric patients were analyzed. Substantial lexical variation was observed for most NF1 features, including variation within and across individual providers. Clinically significant features, such as optic pathway glioma, were documented using numerous nonstandard terms, with preferred terminology appearing in a minority of notes. Cutaneous neurofibromas demonstrated higher internal consistency but lagged behind current clinical trial nomenclature, while plexiform neurofibromas and attention-deficit/hyperactivity disorder were documented more consistently. Documentation completeness also varied across providers and over time, with many previously documented features absent from later follow-up notes. DISCUSSION:Physician-authored EHR documentation of NF1-related features demonstrates substantial lexical variation and incomplete longitudinal capture, which limit the accuracy and generalizability of NLP-based and ML-based phenotyping. Establishing a standardized, data-informed clinical lexicon aligned with current care and research practices represents a scalable strategy to improve interoperability, phenotypic consistency, and readiness for clinical trials and real-world evidence generation in NF1 and other complex neurologic disorders.
BACKGROUND AND OBJECTIVES:Transition of young adults with epilepsy to an adult health care model continues to be challenging because of many barriers. A Quality Improvement project was developed to create a roadmap to assist young adults with epilepsy in successfully transitioning from our pediatric neurology clinic to adult neurology providers for lifetime epilepsy management. METHODS:Young adults with epilepsy aged 18-23 years with normal cognitive development were recruited to participate in our program. We conducted 4 interventions, each with 3 Plan-Do-Study-Act cycles from February 2023 to January 2025. The interventions included roadmap development, setting expectations for transition, expansion of patient communication modalities, and transition documentation. The outcome measure was defined as a successful transition from Dayton Children's Hospital (DCH) neurology clinic to an adult neurology clinic and was calculated by the number of patients who completed their first appointment with their adult neurology provider. RESULTS:Of 102 patients enrolled in the program, we tracked 72 (70%) successful transitions with 26 pending further action (i.e., scheduled appointments, referrals pending approval, and unable to reach patients) and 4 dismissed from the department. Barriers in the process included missed appointments, inability to establish communication with patients, and delayed self-management behaviors. The program was adopted as standard practice in our department and continues to be effective 2 years later. DISCUSSION:The DCH neurology team created and maintained a successful transition program for developmentally normal young adults with epilepsy to transition to an adult neurology clinic and assume responsibility for managing their health care needs.
BACKGROUND AND OBJECTIVES:Acute symptomatic seizures (ASyS) are clinical seizures occurring at the time of a systemic insult or in close temporal association with a documented brain injury. We aimed to determine the 3-year mortality following a first ASyS. METHODS:We previously conducted a prospective, population-based cohort comprising all individuals with a first seizure during 2017 from a defined geographic area. Individuals with ASyS were identified from this cohort using ILAE criteria and stratified by provoking factor. Mortality was assessed at 30 days, 1 year, and 3 years following the event, and age-standardized mortality ratios (SMRs) were calculated at 1 and 3 years using age-matched and sex-matched national mortality data. RESULTS:Among 207 cases of first ASyS, identified from a population of 542,868, there were 61 deaths (29.5%) during 3 years of follow-up. Mortality at 30 days, 1 year, and 3 years was 12.6%, 22.2%, and 29.5%, respectively. The SMR was 19.7 (95% CI 14.4-26.3) at 1 year and 10.4 (95% CI 7.9-13.4) at 3 years. Mean age at first ASyS was 52.1 years and at death 70.5 years. Excluding the substance use group, 3-year mortality rose to 45.5% (50/110). Pneumonia was the most frequent cause of death (17/61, 27.9%). DISCUSSION:ASyS is a common presentation and is associated with markedly increased mortality over 3 years. These findings underscore the prognostic importance of ASyS as a clinical indicator of increased long-term mortality, particularly in medically complex patients.
BACKGROUND AND OBJECTIVES:Psychiatric comorbidities are highly prevalent in people with epilepsy, which adversely affect treatment outcomes. The proper choice of antiseizure medication (ASM) is therefore crucial because different ASMs have varying psychiatric safety profiles. This study investigates the psychiatric tolerability of commonly used ASMs in people with newly diagnosed focal epilepsy. METHODS:This post hoc analysis included participants from the Human Epilepsy Project, an international, multicenter prospective cohort. Of 357 participants aged ≥12 years enrolled within 4 months of treatment initiation for focal epilepsy, those receiving levetiracetam, lamotrigine, or sodium channel blockers (SCBs, including carbamazepine, oxcarbazepine, and phenytoin) monotherapy who completed the Mini International Neuropsychiatric Interview at enrollment were included. Median doses at discontinuation for each treatment group were reported. RESULTS:Of 357 patients, 214 (60%) received levetiracetam, 69 (19%) lamotrigine, and 74 (21%) other SCBs. Treatment groups differed significantly by sex (p = 0.028) and education level (p = 0.001). During the 2-year follow-up, levetiracetam and other SCBs had a significantly higher risk of withdrawal because of psychiatric adverse events compared with lamotrigine (p = 0.001 and p = 0.024, respectively). Most withdrawals occurred early. Multivariable Cox regression showed a higher withdrawal risk for levetiracetam vs lamotrigine (adjusted HR 2.76; 95% CI 1.51-5.04; p ≤ 0.001) and for other SCBs vs lamotrigine (adjusted HR 2.25; 95% CI 1.13-4.47; p = 0.021). Discontinuation doses were substantially lower than maintenance doses across all groups (p < 0.001 for levetiracetam and lamotrigine; p = 0.0022 for other SCBs). Among patients without baseline depression or anxiety (n = 232), discontinuation occurred in 40% of those receiving levetiracetam, 40% receiving other SCBs, and 19% receiving lamotrigine. Consistent with the overall cohort, levetiracetam was associated with a higher risk of discontinuation (OR 2.40 [1.18-5.20], p = 0.020) compared with lamotrigine. DISCUSSION:People who were newly diagnosed with focal epilepsy on ASM monotherapy showed that levetiracetam was associated with approximately 2.8-fold risk of treatment withdrawal compared with lamotrigine because of psychiatric adverse events. Our analysis also demonstrated a better psychiatric tolerability profile for lamotrigine compared with other SCBs. Most discontinuations occurred at significantly lower doses than maintenance therapy, suggesting either failure to reach therapeutic dosing or dose tapering before discontinuation.
BACKGROUND:The central vein sign (CVS) was included in 2024 McDonald criteria but remains underutilized in clinical practice. Implementation of CVS may reduce the requirement for lumbar punctures (LPs). At Nottingham, UK academic multiple sclerosis (MS) center, we implemented a fast-track (FT) pathway incorporating CVS analysis for people referred with imaging suggestive of MS as part of a quality improvement project. We retrospectively reviewed consecutive patients diagnosed with MS referred between March 1, 2024, and July 31, 2025. RECENT FINDINGS:Data from 59 consecutive patients were analyzed. The mean time to diagnosis was 2.9 months in FT pathway and 5.6 months in usual outpatient pathway (Student t test mean 83-day difference, p = 0.003). No people with MS in FT pathway received a LP. The mean cost per patient was £707 (FT) vs £999 (outpatient). IMPLICATIONS:Routine application of CVS within a structured diagnostic pathway accelerated diagnosis, eliminated LPs, and reduced costs. Our findings support a broader adoption of CVS to streamline MS workup.
BACKGROUND AND OBJECTIVES: Although genetic testing is recommended as a standard component of the diagnostic evaluation for epilepsies with unknown etiology, its optimal application in adult populations remains poorly defined. The aim of this study was to assess the diagnostic yield of genetic testing in adult patients with epilepsy, identify associated risk factors, and develop a clinical score to guide patient selection for testing. METHODS: A single-center cross-sectional study was conducted at Stanford University. The Stanford electronic health record cohort discovery tool and manual chart review were used to identify eligible patients aged ≥18 years who were evaluated between 2018 and 2024. Multivariable logistic regression analysis was used to investigate the association between the clinical phenotypes and the probability of detecting pathogenic genetic variants, which served as the basis for the Genetic Risk Index for Seizure Etiology (Gen-RISE). RESULTS: = 0.89). Pathogenic variants were identified in 32.9% of patients, with 2.6% having unrelated pathogenic variants as secondary findings. Low-frequency (<1%) pathogenic variants in the cohort accounted for over 50% of positive findings. Exome sequencing had the highest yield (41.7%), followed by genetic panels (30.3%) and microarray testing (21.8%). Intellectual disability/developmental delay (OR, 3.41, 95% CI [2.18-5.32]), seizure onset before age 3 years (OR, 1.96, 95% CI [1.27-3.02]), and abnormal EEG findings (OR, 1.29, 95% CI [1.00-1.26]) were associated with the diagnosis of genetic epilepsy. Subsequently, we developed Gen-RISE, a clinical tool to estimate the probability of a pathogenic variant related to epilepsy. Gen-RISE above 0 predicted a >50% likelihood of identifying a pathogenic variant, with a sensitivity of 98.6% in an independent literature-based validation cohort. DISCUSSION: Genetic testing for epilepsy is underused, evidenced by marked testing delays. It should be considered for adult epilepsy patients with unknown or suspected genetic etiology because approximately one-third may have identifiable genetic variants. We developed Gen-RISE, a novel and practical, publicly available tool to identify optimal candidates for genetic testing, enhancing diagnostic efficiency and patient care.
BACKGROUND AND OBJECTIVES:Parkinson disease (PD) and other Lewy body disorders are leading contributors to carer distress. In clinical settings, carer needs are not well understood or routinely discussed. When addressed, the focus tends to be on caregiver burden, a broad term that may limit clinicians' ability to provide meaningful support. This study aimed to investigate the priorities of key stakeholders, namely, persons with PD (PwP), informal unpaid carers such as spouses of PwP, and paid caregivers, to help facilitate the development of more targeted, holistic carer support. METHODS:Using a qualitative descriptive research design, virtual semistructured interviews and one focus group were conducted with PwP, informal unpaid carers, and paid caregivers. Data collection and analyses were iterative, and a thematic analysis of coded data was completed. RESULTS:Participants included 10 PwP (60% female, 90% White), 8 informal carers (100% female, 87.5% White), and 6 paid caregivers (75% female, 50% White). Four themes on the perceptions of PD caregiving were identified that highlighted current caregiving priorities. (1) Prior discussions on caregiving roles and expectations are important. Conversations between PwP and carers on the carer's role and individual expectations of caregiving were recognized as foundational to optimal caregiving. (2) The minutiae of caregiving exacerbate caregiver burnout and strain. Routine caregiving tasks and lack of decision-making support contributed to carer burnout and PwP frustrations. (3) Asking for and receiving help with caregiving can be hard for carers and patients. While carers and PwP were reluctant to ask for help, paid caregivers encouraged strategies to do so. (4) Caring and love lie at the core of caregiving. The challenges of PD caregiving were offset by feelings of mutuality of love and care. DISCUSSION:Focused discussions on carer roles and expectations are foundational to improving caregiving experiences. Providing support for these discussions in clinical settings, offering help, and intentionally shifting the focus from burden to the positive aspects of caregiving may foster purpose and resilience among PD carers. Future research should include perspectives of varied stakeholders engaged in providing and receiving care and explore clinical interventions to address carer priorities.
BACKGROUND AND OBJECTIVES:Despite its proven effectiveness, epilepsy surgery for drug-resistant epilepsy (DRE) remains underutilized and frequently delayed. Previous studies of epilepsy duration before surgery-using variable delay thresholds (2-20 years)-were small, single-center cohorts focused mainly on temporal/frontal lobe epilepsy, showed better seizure freedom with earlier surgery, but did not distinguish total epilepsy duration from DRE duration. As contemporary epilepsy surgery now includes broader indications and emphasizes faster evaluation, the timing and impact of evaluation across this wider population remain unclear. We examined factors associated with evaluation timing from DRE diagnosis and its effect on surgical outcomes in a large multicenter cohort. METHODS:Using a prospective database across 29 US centers, we analyzed associations between patient and epilepsy factors and DRE-to-evaluation interval-defined as the interval from DRE diagnosis to phase 1 video-EEG admission, categorized as shorter (<1 year) or longer (≥1 year)-and compared seizure freedom between groups using multivariable logistic regression adjusted for etiology, seizure type, neuroimaging, and surgical factors. RESULTS:Among 1,310 children, 720 (55%) had shorter and 590 (45%) longer DRE-to-evaluation intervals. Shorter interval was associated with lesional epilepsy (OR 1.65, 95% CI 1.30-2.08), focal seizures (2.80, 2.13-3.70), and normal neurologic exams (1.86, 1.49-2.33). Structural congenital and acquired etiologies were linked to shorter interval, while genetic etiologies (1.73, 1.30-2.32) were linked to longer interval. Among 624 surgical patients (357 shorter, 267 longer), seizure freedom occurred in 53% vs 27% (3.04, 2.17-4.29; p < 0.01). After adjustment, longer interval remained independently associated with lower seizure freedom (0.59, 0.35-1.00; p = 0.0497). DRE-to-evaluation interval, not total epilepsy duration, predicted outcomes. DISCUSION:In this first large multicenter study across diverse epilepsy types applying a 1-year benchmark, nearly half of pediatric patients experienced delays, particularly those with MRI-negative, generalized, or genetic epilepsies. Delays from DRE diagnosis were independently associated with reduced seizure freedom, supporting presurgical evaluation within 1 year as an evidence-based quality benchmark.
OBJECTIVES:To clarify the upper limit of epilepsy onset in focal cortical dysplasia (FCD) Type II (FCD)-related epilepsy and to investigate factors affecting long-term surgical outcomes from an open-source database. METHODS:Patients with FCD Type II pathology were included from the Imaging Database for Epilepsy And Surgery. The primary outcome measure was the incidence of adult-onset FCD-drug resistant epilepsy (DRE). Secondary analyses focused on factors affecting long-term seizure-free outcomes after resective epilepsy surgery for FCD-DRE. RESULTS:Thirty-nine FCD-DRE patients were identified. Pathology was Type IIB (n = 30), Type IIA (n = 8), and Type II Not Otherwise Specified (n = 1). Only 5% had adult-onset DRE; 95% had onset before 15 years. Surgery was associated with 71.4% 5-year International League Against Epilepsy Class I outcome. FCD Type IIB was associated with high rate of seizure-free outcome (OR 13.0, 95% CI [1.36-124], p = 0.03). Focal-to-bilateral-tonic-clonic seizures, focal impaired consciousness seizures, prior status epilepticus, sex, hemisphere, age of epilepsy onset, and age of surgery were not associated with 5-year seizure-free outcome. DISCUSSION:Prior data show that ∼5% of FCDs are discovered incidentally. This study elucidates that the majority of FCD-DRE (including those patients treated as adults) is childhood-onset. These data demonstrate that FCD Type II (especially Type IIB) is associated with high rates of durable postsurgical seizure-free outcome.
